The use of a mobile device to obtain clinical photographs is convenient and efficient compared with the traditional use of a medical photographer. It also enhances physician communication and allows ease of photograph storage and accessibility. However, provincial/territorial colleges across the country lack complete and readily accessible information to guide smartphone use for clinical photography. Evaluation of existing guidelines identified significant agreement between college recommendations in six main categories: consent, storage, retention, audit, transmission, and breach. Concise national guidelines pertaining to each of these categories will improve the ability of physicians to understand how to use clinical photography appropriately in the future.

Technological advances in clinical photography have enhanced physician practices and patient care in many medical and surgical fields. Clinical photographs convey a great deal of information about a patient’s condition, and the adjunct of a mobile device allows further enhancement of patient care by facilitating physician communication and education.1-3 Photographs are important to document form and function, track wound healing, and aid in operation planning.4,5 Recent studies have endorsed the efficacy of photography with a mobile device to improve the process of referral to burn centres6-8 and free flap monitoring,9 and to increase confidence in and the accuracy of diagnosis of surgical site infections.10

The use of a mobile device to obtain clinical photographs is convenient and efficient compared with the traditional use of a medical photographer. It also enhances physician communication and allows ease of photograph storage and accessibility. In light of these advantages, it is not surprising that 89% of Canadian plastic surgery residents and attending physicians surveyed by Chan et al.11 use smartphones to take clinical photographs of patients.

However, despite their regular use of smartphones for clinical photography, half of the respondents felt uncomfortable with this practice, citing questions of security, privacy and confidentiality, and unfamiliarity with regional policies as the main reasons for their discomfort. Because health information in photographic form is considered highly sensitive and personal, their concern is founded.12

Given this clinician uncertainty, the primary purpose of our study was to gather information on the accessibility and completeness of guidelines for clinical photography using a smartphone in Canada. Secondarily, we aimed to provide brief direction for clinicians using smartphones for clinical photography. In the future, we hope to use the information gathered to develop a comprehensive set of national guidelines.

Methods

To identify guidelines from each of the 13 provincial and territorial colleges that regulate medical practice, as well as the Canadian Medical Protective Association (CMPA), we sent an email to a representative of each organization asking for information and documents pertaining to the use of a smartphone for clinical photography in six categories. These categories were identified through discussion among the authors of this paper, as well as a legal team:

Consent

Do you have special recommendations for consent regarding photograph taking/sharing using a smartphone?

Storage

How should electronic photographs and text messages be stored in a smartphone?

Retention

For how long should photographs/text messages be stored?

Audit

What data points need to be tracked for audit purposes during smartphone text/photograph sharing?

Transmission

What are the recommendations and requirements for the transmission of clinical messaging and photographs using smartphone technology?

Breach

What constitutes a breach of data on a smartphone?

How should it be contained and who should be notified?

If representatives did not reply to the email, we placed a follow-up telephone call within four weeks of the original email; all colleges were reached by either email or telephone. In addition, we searched the website of each college for clinical photography and mobile telephone guidelines. Top

A ranking system was used to evaluate the accessibility and completeness of the relevant material for each of the six categories. A ranking of two was given if information was readily available on the college website and was deemed to be complete, a ranking of one if website information was incomplete or obtained via email or telephone communication, and a ranking of zero if there was no information on the topic. These scores were not meant to evaluate the quality of the provincial organizations, but rather to assess the completeness of available information.

A second independent reviewer evaluated each organization’s website to confirm results. Copies of emails and transcripts of telephone conversations were forwarded to the second independent reviewer where necessary. Any discrepancy in scores between the two reviewers was reconciled by a third independent reviewer.

Accessibility was scored separately. A ratio of the total number of points scored for completeness divided by the number of documents that were accessed to obtain this information was used to represent a guideline’s accessibility. Thus, high ratios represent greater accessibility and low ratios represent less accessibility.

We reviewed all information available from each of the 13 provincial/territorial colleges and the CMPA, then met to synthesize preliminary recommendations for how to safely use smartphones for clinical photography and transmission in a way that would adhere to the policies of each organization.

A task force, including two privacy lawyers and two plastic surgeons met to revise the preliminary guidelines and develop a summary of recommendations for how to safely use smartphones for clinical photography and transmission based on existing data.

Results

Most of the information gathered came from college websites, rather than through email or telephone conversations. Of the 13 regulatory colleges contacted, 10 provided some relevant information on their websites (Table 1). For most topics (five of six) only incomplete data were available. Relevant and complete information related to retention period was the area most consistently reported, with 10 regulatory colleges providing some relevant information on their website. Only the Collège des médecins du Québec (CMQ) had guidelines for all six categories. Some regulatory colleges with no information on their website (e.g., the College of Physicians and Surgeons of Prince Edward Island) were able to provide select information through email. Seven colleges (54%) were missing guidelines on more than half of the six categories. The least amount of information was available for auditing criteria of smartphone use, as well as the definition and consequences of a breach of patient information on a smartphone.

The number of documents that had to be accessed to find information on all categories varied by province (Table 1). The CMQ had the highest accessibility ranking because only two documents had to be reviewed to obtain information pertaining to each of the six categories of interest. Although the College of Physicians and Surgeons of British Columbia scored high for completeness, its accessibility ratio remained low because six documents required review to obtain all relevant information. Saskatchewan’s college had the lowest accessibility ratio because it scored low for completeness, and the information that was available was scattered among a large number of documents (five). An average of 2.4 documents per college (range 1–6) had to be accessed to find recommendations pertaining to all six categories.

After reviewing all available guidelines, the taskforce (two privacy lawyers and two plastic surgeons) suggested the following summary statements for each of the six categories for how to safely use smartphones for clinical photography and transmission based on existing data.

Consent

Clinicians must document informed consent and recognize that this does not revoke their legal duty to diligently protect patient information.

Transmission

For transmission of data, use Canadian servers that offer end-to-end encryption.

Storage

Clinical photographs should not be stored locally on a smartphone.

Auditing capability

Patient demographics, as well as the details surrounding access to photographs must be tracked.

Retention period

Clinical photographs are considered part of the patient medical record and should be maintained for 10 years or 10 years after the age of majority, whichever comes later.

Breach

Loss of a strongly encrypted smartphone with no photos stored locally on the device is not considered a breach.

Discussion

Consent, transmission, storage, auditing capability, retention period, and breach of information are six important issues to consider for clinical photography using a smartphone. However, national and provincial college guidelines lack explicit and readily available instructions regarding clinical photography using a smartphone and electronic transmission of patient information. Photograph retention is the only category consistently and clearly addressed by the colleges.

As the use of mobile devices for this purpose becomes increasingly ubiquitous, concern over potential breaches in patient confidentiality leading to legal risks to the physician and hospitals will increase along with risks to patients.13-19 The need for efficient clinical photography and immediate transmission of patient information has been emphasized in many studies,2,5-8,20-22 and, as such, it is time that guidelines were adjusted to suit the current technological environment while protecting patient confidentiality.

Of the various categories relating to clinical photography and transmission of patient information, provincial guidelines for photograph retention and storage are most consistently provided: 10 colleges (77%) for retention, five (38%) for storage. The next-best-guided categories are for photograph consent and transmission, with only two colleges (15%) providing sufficient information. The lack of guidelines for clinical photography is concerning, given the rapid progression of smartphone use for this purpose and the associated privacy concerns. Top

Clinical photography is essential to the practice of modern-day medicine, and technological advances in the form of smartphones have allowed improvements to patient care and physician education that are recognized by both physicians and patients.7,21,23-26 To overcome the increased risk of patient security breach, physicians must familiarize themselves with existing guidelines. To do so, these guidelines need to be both comprehensive and readily accessible.

To address an unmet need, our taskforce developed summary statements on six issues. Informed consent should be obtained before taking clinical photographs. Transmission should be done using end-to-end encryption on Canadian servers only. Photographs should not be stored locally on the smartphone. Details regarding access of these photos should be tracked for audit purposes. Clinical photographs should be stored for a minimum of 10 years, as they form a part of the medical record. Loss of a strongly encrypted smartphone with no photos stored locally would not be considered a breach; therefore strict principles for transmission of storage are paramount to safe use of smartphone technology.

These guidelines reflect the current technological environment and aim to provide specific direction on how to securely practice clinical photography using a smartphone. They are the product of a multidisciplinary group discussion, allowing for input from the perspective of the surgeons, and a legal team.

The culture shift of medicine toward a more safe and secure, yet modern, way to communicate with smartphones will take time. Barriers could include education of clinicians on safe storage of data in a telephone or in the cloud and the details of why all patient-related photos are part of the health care record. The varied technological literacy among doctors and the logistics and practicality of adhering to gold standard recommendations in clinical practice could make implementation difficult in some current medical ecosystems. However, we hope that the guidelines will be a reminder and a goal for improved digital professionalism.

Moving forward, it is imperative that physicians be aware of existing guidelines on the safe use of smartphones for clinical photography and work to follow this standard of quality and safety. A newly published comprehensive national guideline is available through the CMA27 and should serve as a reference for the responsible use of clinical photography with a mobile device.

Among health care providers, physicians have significant influence in terms of leading future use of health information technology. Because clinical photography is often used for communication between care providers, the success of implementing any sort of guideline will depend on the breadth and depth of engagement and alignment among physician leaders. Moreover, this issue must involve ongoing discussion, and physicians must come together with a common purpose to ultimately improve patient outcomes and coordinate as an agency for change. Adherence to these guidelines by all physicians is imperative to maintain safe standards to protect health information technology in the future. Top

The use of a mobile device to obtain clinical photographs is convenient and efficient compared with the traditional use of a medical photographer. It also enhances physician communication and allows ease of photograph storage and accessibility. However, provincial/territorial colleges across the country lack complete and readily accessible information to guide smartphone use for clinical photography. Evaluation of existing guidelines identified significant agreement between college recommendations in six main categories: consent, storage, retention, audit, transmission, and breach. Concise national guidelines pertaining to each of these categories will improve the ability of physicians to understand how to use clinical photography appropriately in the future.

Technological advances in clinical photography have enhanced physician practices and patient care in many medical and surgical fields. Clinical photographs convey a great deal of information about a patient’s condition, and the adjunct of a mobile device allows further enhancement of patient care by facilitating physician communication and education.1-3 Photographs are important to document form and function, track wound healing, and aid in operation planning.4,5 Recent studies have endorsed the efficacy of photography with a mobile device to improve the process of referral to burn centres6-8 and free flap monitoring,9 and to increase confidence in and the accuracy of diagnosis of surgical site infections.10

The use of a mobile device to obtain clinical photographs is convenient and efficient compared with the traditional use of a medical photographer. It also enhances physician communication and allows ease of photograph storage and accessibility. In light of these advantages, it is not surprising that 89% of Canadian plastic surgery residents and attending physicians surveyed by Chan et al.11 use smartphones to take clinical photographs of patients.

However, despite their regular use of smartphones for clinical photography, half of the respondents felt uncomfortable with this practice, citing questions of security, privacy and confidentiality, and unfamiliarity with regional policies as the main reasons for their discomfort. Because health information in photographic form is considered highly sensitive and personal, their concern is founded.12

Given this clinician uncertainty, the primary purpose of our study was to gather information on the accessibility and completeness of guidelines for clinical photography using a smartphone in Canada. Secondarily, we aimed to provide brief direction for clinicians using smartphones for clinical photography. In the future, we hope to use the information gathered to develop a comprehensive set of national guidelines.

Methods

To identify guidelines from each of the 13 provincial and territorial colleges that regulate medical practice, as well as the Canadian Medical Protective Association (CMPA), we sent an email to a representative of each organization asking for information and documents pertaining to the use of a smartphone for clinical photography in six categories. These categories were identified through discussion among the authors of this paper, as well as a legal team:

Consent

Do you have special recommendations for consent regarding photograph taking/sharing using a smartphone?

Storage

How should electronic photographs and text messages be stored in a smartphone?

Retention

For how long should photographs/text messages be stored?

Audit

What data points need to be tracked for audit purposes during smartphone text/photograph sharing?

Transmission

What are the recommendations and requirements for the transmission of clinical messaging and photographs using smartphone technology?

Breach

What constitutes a breach of data on a smartphone?

How should it be contained and who should be notified?

If representatives did not reply to the email, we placed a follow-up telephone call within four weeks of the original email; all colleges were reached by either email or telephone. In addition, we searched the website of each college for clinical photography and mobile telephone guidelines. Top

A ranking system was used to evaluate the accessibility and completeness of the relevant material for each of the six categories. A ranking of two was given if information was readily available on the college website and was deemed to be complete, a ranking of one if website information was incomplete or obtained via email or telephone communication, and a ranking of zero if there was no information on the topic. These scores were not meant to evaluate the quality of the provincial organizations, but rather to assess the completeness of available information.

A second independent reviewer evaluated each organization’s website to confirm results. Copies of emails and transcripts of telephone conversations were forwarded to the second independent reviewer where necessary. Any discrepancy in scores between the two reviewers was reconciled by a third independent reviewer.

Accessibility was scored separately. A ratio of the total number of points scored for completeness divided by the number of documents that were accessed to obtain this information was used to represent a guideline’s accessibility. Thus, high ratios represent greater accessibility and low ratios represent less accessibility.

We reviewed all information available from each of the 13 provincial/territorial colleges and the CMPA, then met to synthesize preliminary recommendations for how to safely use smartphones for clinical photography and transmission in a way that would adhere to the policies of each organization.

A task force, including two privacy lawyers and two plastic surgeons met to revise the preliminary guidelines and develop a summary of recommendations for how to safely use smartphones for clinical photography and transmission based on existing data.

Results

Most of the information gathered came from college websites, rather than through email or telephone conversations. Of the 13 regulatory colleges contacted, 10 provided some relevant information on their websites (Table 1). For most topics (five of six) only incomplete data were available. Relevant and complete information related to retention period was the area most consistently reported, with 10 regulatory colleges providing some relevant information on their website. Only the Collège des médecins du Québec (CMQ) had guidelines for all six categories. Some regulatory colleges with no information on their website (e.g., the College of Physicians and Surgeons of Prince Edward Island) were able to provide select information through email. Seven colleges (54%) were missing guidelines on more than half of the six categories. The least amount of information was available for auditing criteria of smartphone use, as well as the definition and consequences of a breach of patient information on a smartphone.

The number of documents that had to be accessed to find information on all categories varied by province (Table 1). The CMQ had the highest accessibility ranking because only two documents had to be reviewed to obtain information pertaining to each of the six categories of interest. Although the College of Physicians and Surgeons of British Columbia scored high for completeness, its accessibility ratio remained low because six documents required review to obtain all relevant information. Saskatchewan’s college had the lowest accessibility ratio because it scored low for completeness, and the information that was available was scattered among a large number of documents (five). An average of 2.4 documents per college (range 1–6) had to be accessed to find recommendations pertaining to all six categories.

After reviewing all available guidelines, the taskforce (two privacy lawyers and two plastic surgeons) suggested the following summary statements for each of the six categories for how to safely use smartphones for clinical photography and transmission based on existing data.

Consent

Clinicians must document informed consent and recognize that this does not revoke their legal duty to diligently protect patient information.

Transmission

For transmission of data, use Canadian servers that offer end-to-end encryption.

Storage

Clinical photographs should not be stored locally on a smartphone.

Auditing capability

Patient demographics, as well as the details surrounding access to photographs must be tracked.

Retention period

Clinical photographs are considered part of the patient medical record and should be maintained for 10 years or 10 years after the age of majority, whichever comes later.

Breach

Loss of a strongly encrypted smartphone with no photos stored locally on the device is not considered a breach.

Discussion

Consent, transmission, storage, auditing capability, retention period, and breach of information are six important issues to consider for clinical photography using a smartphone. However, national and provincial college guidelines lack explicit and readily available instructions regarding clinical photography using a smartphone and electronic transmission of patient information. Photograph retention is the only category consistently and clearly addressed by the colleges.

As the use of mobile devices for this purpose becomes increasingly ubiquitous, concern over potential breaches in patient confidentiality leading to legal risks to the physician and hospitals will increase along with risks to patients.13-19 The need for efficient clinical photography and immediate transmission of patient information has been emphasized in many studies,2,5-8,20-22 and, as such, it is time that guidelines were adjusted to suit the current technological environment while protecting patient confidentiality.

Of the various categories relating to clinical photography and transmission of patient information, provincial guidelines for photograph retention and storage are most consistently provided: 10 colleges (77%) for retention, five (38%) for storage. The next-best-guided categories are for photograph consent and transmission, with only two colleges (15%) providing sufficient information. The lack of guidelines for clinical photography is concerning, given the rapid progression of smartphone use for this purpose and the associated privacy concerns. Top

Clinical photography is essential to the practice of modern-day medicine, and technological advances in the form of smartphones have allowed improvements to patient care and physician education that are recognized by both physicians and patients.7,21,23-26 To overcome the increased risk of patient security breach, physicians must familiarize themselves with existing guidelines. To do so, these guidelines need to be both comprehensive and readily accessible.

To address an unmet need, our taskforce developed summary statements on six issues. Informed consent should be obtained before taking clinical photographs. Transmission should be done using end-to-end encryption on Canadian servers only. Photographs should not be stored locally on the smartphone. Details regarding access of these photos should be tracked for audit purposes. Clinical photographs should be stored for a minimum of 10 years, as they form a part of the medical record. Loss of a strongly encrypted smartphone with no photos stored locally would not be considered a breach; therefore strict principles for transmission of storage are paramount to safe use of smartphone technology.

These guidelines reflect the current technological environment and aim to provide specific direction on how to securely practice clinical photography using a smartphone. They are the product of a multidisciplinary group discussion, allowing for input from the perspective of the surgeons, and a legal team.

The culture shift of medicine toward a more safe and secure, yet modern, way to communicate with smartphones will take time. Barriers could include education of clinicians on safe storage of data in a telephone or in the cloud and the details of why all patient-related photos are part of the health care record. The varied technological literacy among doctors and the logistics and practicality of adhering to gold standard recommendations in clinical practice could make implementation difficult in some current medical ecosystems. However, we hope that the guidelines will be a reminder and a goal for improved digital professionalism.

Moving forward, it is imperative that physicians be aware of existing guidelines on the safe use of smartphones for clinical photography and work to follow this standard of quality and safety. A newly published comprehensive national guideline is available through the CMA27 and should serve as a reference for the responsible use of clinical photography with a mobile device.

Among health care providers, physicians have significant influence in terms of leading future use of health information technology. Because clinical photography is often used for communication between care providers, the success of implementing any sort of guideline will depend on the breadth and depth of engagement and alignment among physician leaders. Moreover, this issue must involve ongoing discussion, and physicians must come together with a common purpose to ultimately improve patient outcomes and coordinate as an agency for change. Adherence to these guidelines by all physicians is imperative to maintain safe standards to protect health information technology in the future. Top